Economic Evaluation of Public Health Interventions: An Application to Interventions for the Prevention of Violence Against Women and Girls Implemented by the "What Works to Prevent Violence Against Women and Girls?" Global Program

What Interventions are Cost Effective in Reducing Violence Against Women? A Scoping Review

PURPOSE

To systematically summarise the recent literature on the cost and cost effectiveness of interventions implemented to reduce violence against women (VAW) and decision frameworks guiding resource allocation.

METHOD

A scoping review of scholarly and grey literature on the cost-effectiveness and/or resource allocation for interventions addressing intimate partner violence (IPV), dating violence and non-partner sexual violence perpetrated against women aged 15 years and over. All settings and contexts were eligible, with papers published in English between 2010 and March 2023 included.

RESULTS

Nineteen papers fulfilled the inclusion criteria reporting the cost, cost savings and/or cost effectiveness of 24 interventions to prevent IPV and to a lesser extent, other forms of interpersonal violence. Among the 16 economic evaluation studies reviewed, four types of interventions were cost effective in multiple settings or studies, including community activism (Uganda, Ghana), gender transformative interventions with couples and individuals (Ethiopia, Rwanda), specific justice and law enforcement measures (USA) and a combined personnel training, support, and referral programme in General Practice in the UK. Other interventions were cost effective in a single study or had conflicting evidence. Three remaining papers conducted a partial evaluation or cost appraisal providing limited information on the cost or cost-savings of other implemented interventions. No frameworks on resource allocation for the prevention of VAW were identified.

CONCLUSION

While there is some evidence of cost effectiveness emerging for interventions implemented in specific contexts, overall, we find the recent evidence on costs and cost effectiveness of interventions for the prevention of VAW to be limited. Embedding economic evaluation in future effectiveness trials will build critical evidence needed to inform policy and resource allocation decisions based on the value-for-money of interventions. Modelling the benefits and costs of interventions to better understand the societal impacts of programmes at scale is a further research opportunity.

The Economic Cost of Violence Against Women and Girls in Low- and Middle-Income Countries: A Systematic Review of the Evidence

Evidence demonstrating the economic burden of violence against women and girls can support policy and advocacy efforts for investment in violence prevention and response programming. We undertook a systematic review of evidence on the costs of violence against women and girls in low- and middle-income countries published since 2005. In addition to understanding costs, we examined the consistency of methodological approaches applied and identified and assessed common methodological issues. Thirteen articles were identified, eight of which were from sub-Saharan Africa. Eight studies estimated costs associated with domestic or intimate partner violence, others estimated the costs of interpersonal violence, female genital cutting, and sexual assaults. Methodologies applied to estimate costs were typically based on accounting approaches. Our review found that out-of-pocket expenditures to individuals for seeking health care after an episode of violence ranged from US$29.72 (South Africa) to US$156.11 (Romania) and that lost productivity averaged from US$73.84 to US$2,151.48 (South Africa) per facility visit. Most studies that estimated provider costs of service delivery presented total programmatic costs, and there was variation in interventions, scale, and resource inputs measured which hampered comparability. Variations in methodological assumptions and data availability also made comparisons across countries and settings challenging. The limited scope of studies in measuring the multifaceted impacts of violence highlights the challenges in identifying cost metrics that extend beyond specific violence episodes. Despite the limited evidence base, our assessment leads us to conclude that the estimated costs of violence against women and girls are a fraction of its true economic burden.

What will it cost to prevent violence against women and girls in low- and middle-income countries? Evidence from Ghana, Kenya, Pakistan, Rwanda, South Africa and Zambia

Violence against women and girls (VAWG) is a global problem with profound consequences. Although there is a growing body of evidence on the effectiveness of VAWG prevention interventions, economic data are scarce. We carried out a cross-country study to examine the costs of VAWG prevention interventions in low- and middle-income countries. We collected primary cost data on six different pilot VAWG prevention interventions in six countries: Ghana, Kenya, Pakistan, Rwanda, South Africa and Zambia. The interventions varied in their delivery platforms, target populations, settings and theories of change. We adopted a micro-costing methodology. We calculated total costs and a number of unit costs common across interventions (e.g. cost per beneficiary reached). We used the pilot-level cost data to model the expected total costs and unit costs of five interventions scaled up to the national level. Total costs of the pilots varied between ∼US $208 000 in a small group intervention in South Africa to US $2 788 000 in a couples and community-based intervention in Rwanda. Staff costs were the largest cost input across all interventions; consequently, total costs were sensitive to staff time use and salaries. The cost per beneficiary reached in the pilots ranged from ∼US $4 in a community-based intervention in Ghana to US $1324 for one-to-one counselling in Zambia. When scaled up to the national level, total costs ranged from US $32 million in Ghana to US $168 million in Pakistan. Cost per beneficiary reached at scale decreased for all interventions compared to the pilots, except for school-based interventions due to differences in student density per school between the pilot and the national average. The costs of delivering VAWG prevention vary greatly due to differences in the geographical reach, number of intervention components and the complexity of adapting the intervention to the country. Cost-effectiveness analyses are necessary to determine the value for money of interventions.

Cross-disciplinary intersections between public health and economics in intimate partner violence research

Research on intimate partner violence (IPV) has progressed in the last decade in the fields of public health and economics, with under-explored potential for cross-fertilisation. We examine the theoretical perspectives and methodological approaches that each discipline uses to conceptualise and study IPV and offer a perspective on their relative advantages. Public health takes a broad theoretical perspective anchored in the socio-ecological framework, considering multiple and synergistic drivers of IPV, while economics focuses on bargaining models which highlight individual power and factors that shape this power. These perspectives shape empirical work, with public health examining multi-faceted interventions, risk and mediating factors, while economics focuses on causal modelling of specific economic and institutional factors and economic-based interventions. The disciplines also have differing views on measurement and ethics in primary research. We argue that efforts to understand and address IPV would benefit if the two disciplines collaborated more closely and combined the best traditions of both fields.

"Our Choice" improves use of safer conception methods among HIV serodiscordant couples in Uganda: a cluster randomized controlled trial evaluating two implementation approaches

Background

Safer conception counseling (SCC) to promote the use of safer conception methods (SCM) is not yet part of routine family planning or HIV care. Guidelines for the use of SCM have been published, but to date there are no published controlled evaluations of SCC. Furthermore, it is unknown whether standard methods commonly used in resource constrained settings to integrate new services would be sufficient, or if enhanced training and supervision would result in a more efficacious approach to implementing SCC.

Methods

In a hybrid, cluster randomized controlled trial, six HIV clinics were randomly assigned to implement the SCC intervention Our Choice using either a high (SCC1) or low intensity (SCC2) approach (differentiated by amount of training and supervision), or existing family planning services (usual care). Three hundred eighty-nine HIV clients considering childbearing with an HIV-negative partner enrolled. The primary outcome was self-reported use of appropriate reproductive method (SCM if trying to conceive; modern contraceptives if not) over 12 months or until pregnancy.

Results

The combined intervention groups used appropriate reproductive methods more than usual care [20.8% vs. 6.9%; adjusted OR (95% CI)=10.63 (2.79, 40.49)], and SCC1 reported a higher rate than SCC2 [27.1% vs. 14.6%; OR (95% CI)=4.50 (1.44, 14.01)]. Among those trying to conceive, the intervention arms reported greater accurate use of SCM compared to usual care [24.1% vs. 0%; OR (95% CI)=91.84 (4.94, 1709.0)], and SCC1 performed better than SCC2 [34.6% vs. 11.5%; OR (95% CI)=6.43 (1.90, 21.73)]. The arms did not vary on modern contraception use among those not trying to conceive. A cost of $631 per person was estimated to obtain accurate use of SCM in SCC1, compared to $1014 in SCC2.

Conclusions

More intensive provider training and more frequent supervision leads to greater adoption of complex SCM behaviors and is more cost-effective than the standard low intensity implementation approach.

Trial registration

Clinicaltrials.gov, NCT03167879; date registered May 23, 2017.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-021-01109-z.